Monday, April 28, 2008

Post-Deception Medicine

I'm on vacation and snatched an hour or so of internet time to check email, but I couldn't resist a quick entry alerting readers to a couple of hot items. First, today's New York Times published this article by Gardiner Harris reporting that the major association of medical schools has unveiled its new policy on drug company gifting. And the news is tremendous. The Association of American Medical Colleges now recommends that "drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff and students in all 129 of the nation’s medical colleges...." In addition, "the report recommended that medical schools should 'strongly discourage participation by their faculty in industry-sponsored speakers’ bureaus,' in which doctors are paid to promote the benefits of drugs and devices."

And in a feat of good timing, the Prescription Project has released a series of "toolkits" to help hospitals and academic medical centers create the conflict of interest policies that the parent organization now recommends. You can read more about this here.

40 comments:

These med schools are competitors, providing inferior CME. They have the credibility of Ford salesmen criticizing a Toyota.

I still await data on what harm has been done to patients or doctors by sponsored CME. In the absence of such proof of harm, the pronouncements from these academics constitute expression of mere bias, self-serving puffery, and unfair bashing of a superior competitor.

Kali: The average, adequate doctor will lose money on sponsored activities. Fees are half those earned in clinical care. These token fees represent charity, sharing and giving back for a life of high privilege.

Dan's income is so atypically, and inexplicably low, such fees may have a distortion effect on his care. Harvard residency failed to teach him enough clinical care to make his services worth as much as those of an advanced nurse practitioner. Or else, he does not know how to locate his practice in a place where he is needed. He should move to the interior of the nation for an immediate jump in income, even with the level of his Harvard skills.

I think the pendulum is swinging against gifts from drug companies, and I think a national recommendation for all medical schools is significant.The schools will probably shrug their collective shoulders, some will enact new policies, and business will continue as usual.It's hard to convince people that gifts are a bad thing, without making them feel like you think you're superior to them. It's a tricky game, so the more voices we have saying the same thing, the better.Kudos to Carlat for taking time out of vacation to keep us up to date on drug company news.

But, after a quick read, the report does not suggest banning participation on speakers' bureaus, it just discourages it. The report puts no restrictions on company sponsored CME as long as it is accredited (and we know that accredited CME done by a MECC but sponsored by a commercial firm is often biased). Not not only does the report not ban larger conflicts of interest (consulting agreements, service on advisory boards, service on corporate boards of directors), it seems to encourage them, and does not even suggest disclosure (see page 23).

I will likely be blogging about this soon myself.

But ata school following all provisions of this report, a resident might be banned from accepting a slice of pizza from a company on whose board his or her department chair (or dean of medicine, or CEO of the medical center, or university president) sits.

By the way, not only were some of the authors of this AAMC report pharma or device executives, some other authors listed as academics are also directors of large for-profit health care corporations.

The AAMC did not see fit to disclose any potential conflicts of interest affecting the authors of this report.

Fresh postings are always appreciated, but take time off Dr C, you need rejuvenation! Haven't you told that to a patient?

I found Dr Poses' comments above to be interesting. As I am skeptical of our alleged leaders, note a letter to the editor in the July 2007 issue of Current Psychiatry re an editorial piece by Henry Nasrallah advocating for "disruptive" new drugs. Douglas Steenblock, MD, wrote, "I do not know if Dr Nasrallah has ties to the pharmaceutical industry, but I do know that only a fierce critic of pharmaceutical companies could credibly suggest that we take steps to make this enterprise more lucrative that it already is."He goes on to write, "With all due respect, his (Dr N's)3 ideas bore an uneasy resemblance to a corporate lobbyist's speaking points." The next sentence says it all: "His recommendation that drug companies receive a pass in terms of product liability particularly is outrageous." The editor of a fairly popular journal is advocating for this!?

Also relating to this alleged plan that is words, not deeds, until proven otherwise, is well said in a column by Catherine Fullerton, MD, also in a July 2007 piece in Clinical Psychiatry News: "Unfortunately, a financial ban is not possible as psychiatric programs and professional organizations currently struggle to find funds to support teaching and conferences...we want experts to influence both guidelines for clinical practitioners and the development of potential new therapies. Insisting on a separation may prove shortsighted."She goes on to say, "Ignoring the issues (dialogue between industry and clinical research) leaves a vacuum into which lawyers and policy makers will rush to dictate changes that we, as psychiatrists, may not desire." Just what I would want, lawyers and politicians to set policy. People rarely influenced by money. I hope you read the sarcasm in that last sentence!

My interpretation of what is said by these supposed leaders thus far: there is more scrutiny of this matter of pharmaceutical influence in education, so we (as corrupted physicians and hospital administrators) will advise new policy and wait for the winds to die down, perhaps a new storm to divert attention, and then sit back down and enjoy the flow of dough. I've been more than just skeptical of a popular journal like Current Psychiatry, probably forwarded to every psych resident in the U.S., propagating this subtle message through its editor.

I've asked you before, Dr C, of your take on this journal and still have no reply. The issue of advertisements in journals was debated in recent commentary postings following a posting by you, so shouldn't we be looking at that role if it (access of journals supplied in training programs) legitimately is a factor in education of residents?

I assume you'll consider an answer once back from vacation. In the meantime, is anyone else besides me both furious and distressed to read in Dr Poses's comments that it is possible that authors of the AAMC report were pharma and device executives, and other authors listed as academics are directors of large for-profit health care corporations?

Come on folks, what's the worst addiction in this culture? MONEY! You think this group, entrenched in positions of power and influence, will give in to what appears a simplistic announcement? I always hope what is posted here is true and correct.I've seen the liars and manipulators; I'm ashamed to say they have been colleagues.

I hope this blog empowers as many as able to fight this travesty of medications trumping common sense.First, do no harm!

Here Here THerapy First! I agree. In meeting Dr Nasrallah myself and asking a question at a breakfast where he was paid speaker, he was blatantly blinded by bias to his drug seroquel it was obvious to me.

I would agree, however, that we certainly dont need to leave these policies up to politicians and attorneys, the most sociopathic of all institutions.

Yes, every few years, someone like Nasrallah comes along who is so completely in a company's pocket that it shocks the conscious. Remember Norman Sussman and his year-round promotion of BuSpar (buspirone) some years ago?

First, mind a bit of catch-up? On January 11, 2008, and January 22, 2008, Dr. Carlat commented on the Macy Foundation’s report calling for the end of commercial support of medical education. I bring your attention to criticisms of the Macy Foundation’s report on a blog, Conversations on CME, at http://convcme.wordpress.com/?s=Macy&searchbutton=Go%21. I haven’t figured out who writes this blog.

I appreciate Dr. Poses’ scathing comments about the AAMC’s latest report on financial conflicts of interest in academic medicine. By “latest”, I bring your attention to a February 2008 AAMC report, “Protecting Patients, Preserving Integrity, Advancing Health: Accelerating the Implementation of COI Policies in Human Subjects Research”. “This report, issued February 2008 by the AAMC and the Association of American Universities, calls on all medical schools and major research universities to develop and implement institutional COI policies within the next two years, and to refine standards for addressing individual financial COI.” Go to www.aamc.org/research/coi/start.htm for links to these two reports and others.

This is all pretty high-fallutin'. You geniuses have forgotten something. A fact.

Cite a fact of a harm done to a patient or to a doctor by this industry sponsorship. Even paranoid schizophrenic 9/11 Conspiracy theorists claim the fall of building seven was like a timed demolition sequence, and cite the melting point of metal. So far, these wackos have more facts and persuasiveness than the left wing ideologues here.

I, too, would like to thank Dr. Poses for his comments about the AAMC’s latest report on financial conflicts of interest in academic medicine. I hope he takes a moment to write Gardiner Harris of the NY Times to alert him to these facts.

Sorry the following is off the path of this blog discussion, but for those of you who get Psychiatric Times, there is a supplement issue out now (April 08, page 40-41) that has a wonderful piece written by a patient who's therapist passed away and how the patient struggled to deal with the loss. What I find so tragic is how both colleagues and the insurance were so clueless or callous in handling the situation.

To relate this article to this site, I believe the feedback that is offered at times by patients is worthwhile and educational. I would like to offer though, the push for changes has to come equally by your block as an invested part of this equation. If you believe that psychiatrists are not treating you as individuals, then speak out via complaints, or more outwardly, by looking for another MD if concerns are brushed off or invalidated.

There are times I wonder if this field is lost. Are we really advocates or lackeys? So will we fight for what is right, or what is convenient? As I always say, evil thrives when good men lie silent. I hope James' comment to Dr Poses to alert the media is considered.

When you think about it, we are talking about the next generation of colleagues we can protect here by pushing for these limits.

The article describes sales techniques. There are no data showing any harm to patients, nor any increase in cost that would not have happened from evolving standard of care, nor undue influence on the doctor.

I love Bud Light commercials. I record them to view them over and over. Bud Light gives me an immediate headache. No effective sales message could ever get me to drink Bud Light.

No drug rep could induce to start a patient or to maintain a patient on a drug that would not help that patient.

When the patient is doing well, clinical care is highly lucrative, fun, and a source of self-pride. When the patient is not doing well, clinical are is a financial disaster, hell on earth, and a disgrace to the doctor.

Find a doctor who would trade that for a sandwich or a pen, or even massive amounts of speaker fees. I will show you a failed clinician. The latter will not be prescribing much anyway.

you're repeating yourself, sir. The bud light reference gives you away. Something new at least to entertain and enlighten?

By your standards, "when the patient is not doing well, clinical care is a disaster, hell on earth, and a disgrace to the doctor", is a falsehood, per the practice of too many psychiatrists.

When the patient is not doing well, he/she will need to come in for more visits, more interventions will be needed i.e. more drugs, the failure is passed onto the patient for not responding to the treatment for the diagnosis du jour, and the insurer will refuse more visits as the DSM 4 is not being followed per the algorithms.

I appreciate your transparency per comment to James in another posting recently. Don't rage at us though, because most of us involved in this site do care and would work with you if you are willing to listen. The law and psychiatry don't mix, sir. The law is black and white; psychiatry is gray. See the light!

Well, TF, being that I had to basically state civil liberty speeches and basically be a mother-advocate-attorney in mental health court to prevent my daughter from a psychiatrist's discharge plan to a state institution (and won)I do believe though you are speaking general law--that law and psychiatry are in essence equally bound, because when it comes to detainment or forced medication, or malpractice, one goes hand in hand in a very not so gray area. Most people have no idea mental health courts exist. I didn't. Until I was sworn in as a Guardian ad Litem under oath that I was watching out for my daughter's interest not my own. I spent equal days in court learning the "ropes" by observation so I couldwin, the same days I was visiting in the psych wards, meeting drug reps from AstraZeneca pimping Seroquel for Borderliners.Interesting discussion here as usual. Sorry to disappoint you, though TF, it does seem to be the same sorry souls here commenting, but that's the way it goes sometimes. More people read than comment btw is typical blog standards. Start one!

Stephany:I appreciate your recommendations here and the other posting about starting a blog, but that is not my style for several reasons: the most important is this acceptable level of anonymity that is too opague in regards to commenters; and the other is you need to practice some maintenance of your site, in my opinion about daily, and I am a bit annoyed that Dr C's lack of commenting in between his own postings shows me either he is not interested or available.

My involvement here is the best I can offer. Tell these other people at your site to read here and participate as able and comfortable. I would hope Dr C would not mind non-clinicians giving feedback, and more press would lead to more viability and credibility.

I stand by my comments in my april 29 8PM posting: the push for changes by your block (as patients)as an invested part of this equation (getting changes in the health care system to better patient care).

Just for the record, I have had to retype those stupid word verification letters a second time at least twice since it started.That is annoying, spammers kept out be damned!

"one can argue whether using unprincipled means to increase profits is socially responsible behavior. But if the reality is that maximum profits is the predominant ethos of the business world, then all of the drug company policies described in this book make sense- that is, from a business point of view."

"But the drug industry is unlike most other businesses. Drug companies aren't manufacturing toaster ovens or sunglasses, but extremely potent chemicals that people-medically ill people- require. Minor deviations from medical principles can cause widespread harm. I agree with Dr Catherine DeAngelis, the editor in chief of JAMA, who in 2000 wrote, 'Using business ethics without tempering them with the needs of society simply is not working.'"

These are the stuff of colleagues that should enrage and empower those with a conscience and interest in the well being of society. CME credits? That's a start. Corrupted and indifferent providers, now there's a group that needs to be monitored.

The left wing ideologue feels free to call other people deceptive, liars, immoral. It's just that others cannot point to the hypocrisy of the left wing ideologue. Most of the posts here contain personal attacks. For example, not only personal attacks, but shunning of drug reps who did nothing wrong but point to scientific article, and ask perfectly appropriate questions on clinical goals.

This blog never points out those attacking sponsored activities of drug companies are competitors advocating for their own economic interest. If drug companies pass their funding through medical schools, left wing foundations, and self-dealing professional societies providing inferior CME programs, all argument ends. These self-dealing left wing ideologues are a trip.

This blog relentlessly produces biased hate speech totally devoid of data or facts showing any harm to doctors or patients.

Thank you for the clarification. Just a piece of advice: if you are going to challenge the system, get used to some mudslinging, at the very least. Similar to the saying, "you can take my gun when you pry it from my cold dead fingers", prepare for those who will come at you with, "you can take away my cash cow when I am beyond irrelevant."That is what needs to be done, to make pharmacology not the principle, but the adjunct. As long as colleagues accept and co-sell that mental illness is a biochemical imbalance, no one of significance or importance will sign on to this challenge to control the role of big pharma in CMEs. If you have been around, you know who and what the old guard is capable of.

Watch your back in this apa committe process. Prove me wrong you are not getting set up!

I passed out copies of the March 27 posting about S Ahari's revelations as a former rep, and yet you watch today's feasting on the rep du jour's lunch, and I don't sense a lot of concern or conscience by the readers.

Maybe Congress should pick up on this: give a free meal before they vote on the next war, and full bellies will give full support!

Had some free time today at the office and saw this fax in our machine:from neuroscience CME--Pharmacology of Atypical Antipsychotics: clinical impact on efficacy and safey; moderator is Charles Nemeroff and faculty is David Dunner and Daniel Haupt.It goes on to note this activity offers CE credit for Physicians, BUT WAIT, also for psychologists, case managers, social workers, and for nurses and pharmacists. And is sponsored by BristolMyers and Otsuka Pharmaceuticals.

For those not familar with those companies, Abilify's parent.

So the point to this comment: why are CMEs offered to non-prescribing professionals, and with Abilify getting new indications what seems to be every month, what disgusting agenda are they selling now?

the site is www.neuroscienceCME.com/CM308, or call 877.cme.pros .

You wonder why I am skeptical the agenda to push widespread use of atypicals is out there. See for yourselves!

Still with down time at the clinic, so came across this little gem in NeuroPsychiatry Reviews, April 08 issue, page 12 (www.neuropsychiatryreviews.com for you internet junkies alone):

When marketing goes straight to your head: in this little brief, it notes a study done in which participants rated their enjoyment of samples of differently priced wines, the 20 raters reported that they enjoyed the expensive version more, and fMRI confirmed the increased experience of pleasantness by showing increased blood-oxygen-level-dependent activity in the medial orbitofrontal cortex (an area of the brain believed to encode experienced pleasantness for odors, taste, and music).

So, the take home message today folks, is be sure to tell your patients that atypical antipsychotics cost a heck of a lot more than typicals, so patients can feel that pleasantness real fast! Just don't let their wallets hear the conversation.

Who thinks up this crap to study it in the first place?! If anyone hears of a study that compares Molson beer to american beers, contact me ASAP. I bet Debbie Boone would have never guessed her song would have new meaning in 2008! (you light up my life)

By the way, Dr C, are you at the APA convention so no new postings this week too?

Is it possible others do not care about this subject because it has no importance outside of the self-dealing coterie of left wing competitors for the CME dollar?

Is it possible that social workers are curious, and should learn more about the medications that dozens of their clients take? Is it OK that they try to answer questions about these meds with a bit more facts than available on Wikipedia?

To answer the above question, I would choose NOT to swallow any neuroleptic unless I had to because my psychiatric illness deemed it appropriate to take such medication. That is the point I have been making for, oh, what, 2 or more months now?

Let me educate you a bit further: when non-prescribing providers learn a little bit about medication, they seem to become grandiose and tell the patient too much and are too directive with medication needs and responses. Then, they dump it on providers like me to demystify and clarify what is the reality of the treatment process, usually making it more difficult to encourage compliance.

No, the question you should be asking NOT of me but of the pharmaceutical industry is why do they continue to market to those who do not write the Rxs; or does the reality of they want to further barrage us as the providers of the pills with falsehoods and expectations the naive and ignorant believe when a rep pries with pens, props, and free food.

Do you get the concept of reciprocity, sir!? I do, and I do not like being preyed on. I doubt you would either.

Interesting day for material to offer to this commentary site. Check out US News & World Report magazine's(www.usnews.com) letters to the editor for the May 12 issue.

I'm not going to type them in here, but the following quotes reveal why it will be hard if not impossible to see the APA or AMA give up Pharma money:

"I see that graduates coming out of medical school take into consideration financial reimbursment in relation to hours worked and can't help but come to the conclusion that primary care does not offer the financial rewards of other specialties" per Robert Potter Jr MD"There are many doctors who do what is best for their patients at the expense of their finances, their sleep, and time with their families. As the trends continue, there will be far fewer. Adjusted for cost of living, I make less now as a busy family doctor than I did 10 years ago." by Hope E Ring MD"I don't remember when seeing your family doctor or going to the hospital became an industry to be milked for stockholder profits or abused by those who influence our government for a piece of the taxpayer's pie." by Robert Seward

All of these quotes were in reference to an article in the April 7-14 issue that spoke of the dwindling committments to primary care from medical students in the past decade or so. I believe you can infer that as physicians see their income stream further squeezed by other sources, they will not give up the golden idol of the pharmaceutical industry. The entitlement alone said by colleagues is pervasive.

If you want to impact on the role of pharma, you'll have to go after health insurers at the same time, if not first. Oh, wait a minute, I forgot. We had that chance and just sat on our butts and did nothing. There's a precedence!

TF: Pretend everyone you know, including a trusted psychiatrist, wants you on a neuroleptic. He says, "I have no preference. They are all equally acceptable (scientifically true). You choose one. You know neuroleptics. Which one do want for yourself?"

The left wing ideologue front organizations do not want to end sponsored CME. They want the sponsorships funneled through them, so they may have their take, like a Tony Soprano. The loudest critics all are providers of inferior CME, that does not compete well. The loudest critics have to give up all their advantage from paid advertising before they get the slightest credibility. These are biased, self-dealing, misleading hypocrites.

A universal view from the APA newsroom: very little news to report from the APA. A few impressions for what its worth:

The NIMH -- which has home turf here in D.C. -- is pushing PTSD and related disorders, in addition to Deep Brain Stimulation for Treatment Resistant Depression (with Helen Mayberg, MD).

E. Cameron Ritchie, MD, in "Psychological Effects of War: From the Battlefront to the Home Front and Back Again," was quoted as predicting that suicides among returning Iraq veterans will equal war-time casualties.

A plethora of posters for the atypicals support potential approval for other indications, including depression. Sorry TF, but all the atypicals make strong showings. Overall, the bipolar-dominated programs of the last few years have been transplanted by schizophrenia-dominated symposia under banner heads of Genetics, Chronic Disease Models, and Brain Imaging.

An interesting program put on by a new group titled "Medical Crossfire" is unique enough to warrant mention and might be a new model of things to come.

DSM-V Research Planning is underway and should be making more news but seems to be flying under the radar, which is confusing to me.

Also of note is that there seems to be less industry-sponsored programs, overall, and that firewalls between sponsors and speakers are real. As the chairman of one major dinner told me, "I don't know how XYZ Company will feel after this night is over."

I'm already en route from the meeting. No doubt that DC and others will have more to report from the last few days. -J

thank you for your report. As I had one of the most disturbing evenings of patient care I have had in a long time. I sign off from this blog offering you and invested readers these final observations:

1. Inpatient care is a joke until proven otherwise. Patients are now being discharged with no meds and no discharge info to the outpatient provider,who is left to figure out A. is the patient stable enough to leave the office and B. what the hell happened to warrant a 3, 5 even 7 day admit that there is no substance to report for continuity of care.2. Addiction is now a primary psychiatric disorder but can't be coded that way still, so again the outpatient provider has to explain why the 3 med regimen isn't working because the patient is only 1 week out of detox and not involved in a substance abuse program.

3. Primary care docs think they are psychiatrists and prescribe the most fascinating regimens, yet when the patient is still not better, if not worse due to side effects and/or drug-drug interactions, then the outpatient provider has to sift through the debris of clueless care interventions and explain that therapy is a treatment intervention in and of itself.

I am not suicidal, but if I don't wake up tomorrow, I hope I would be ok with that. Crestfallen is an understatement. I hope you and the rest of you can support Dr C in his efforts. I'm done with the carelessness, cluelessness, corruption, and stupidity. You are all better people than me if you can stomach this crap.

Thanks for your support and kind words these last couple of months.SC: I wish you well in your endeavors and pursuits. I won't lie though, I won't miss your pontifications. you tried though, I'll give you that.

TF: If someone is interfering with your clinical care, can you let me know privately without using names? The opposition to this left wing blogger is a small subset of the general defense of clinical care from the vicious enemies surrounding it. There is no path but the path of resistance. Resistance is a duty to the patient.

TF: two quick questions. One, can you give me an example of a "classic" primary care physician's prescribing mistake? And, two, your comments about comorbid substance abuse is proof positive that the DSM-V needs to address carefully and transparently a new subset of problems that only you and clinicians like you can tell them. I would highly suggest that the DSM-V editors set-up an efficient means of communicating with physicians on the front-lines and not just the usual experts. Hang in there. Peace, j

I'm new here, but love the tone. I'm amazed that psychiatrists supposedly understand rationalization and denial, but employ it full-force where the drug industry is concerned. They remind me so much of the politicians who fervently believe that the perks received from lobbyists have absolutely no effect on their judgment...rrrright.Sometimes I feel like I'm the last person left who hasn't fallen prey to the invasion of the mind snatchers. Good to hear from some likeminded souls.